Reduced Port Laparoscopic D2 Subtotal Gastrectomy - How I do it (Video Presentation)

Authors
Dr Geraldine Lei, Dr Charleen Yeo, Dr Aung Myint Oo

Affiliations
Upper Gastrointestinal and Bariatric Surgery, Tan Tock Seng Hospital, Singapore

Introduction
Reduced port laparoscopic surgery (RPLS) is gaining popularity among surgeons, with increasing advancements in laparoscopic surgical techniques and expertise. It has been gradually applied to a wider variety of conditions, from benign to malignant. The difficulty in RPLS lies in the lack of retraction, making lymphadenectomy particularly challenging. In this video presentation, we demonstrated a case of reduced port laparoscopic D2 subtotal gastrectomy in an elderly gentleman with incisura gastric cancer.

Methods
Our patient was an 83-year-old gentleman with a past medical history of hypertension. He presented with melena and abdominal pain of three days’ duration. Gastroscopy was performed and showed a large 2 cm Forrest 3 lesser curve gastric ulcer. Biopsies were taken and histology was proven to be gastric adenocarcinoma. Staging computed tomography scan did not reveal any distant metastasis. Patient underwent elective reduced port laparoscopic D2 subtotal gastrectomy with Billroth 2 reconstruction after two weeks of prehabilitation.

Results
Our video presentation demonstrated the techniques for RPLS including adequate trianguation of working ports and the use of gauze for retraction. Operative duration in our case was 5 hours and blood loss was minimal. Our patient recovered well postoperatively. He was started on oral feeds on postoperative day (POD) 1 and escalated to solid food on POD 3. Surgical drain was removed on POD 4 and he was discharged on POD 4. Final histology was a stage III pT3N3a, G3 poorly differentiated gastric incisura adenocarcinoma with lymphovascular and perineural invasions, margins clear, 10 out of 47 lymph nodes positive for nodal metastasis.

Conclusion
With proper techniques as demonstrated in our video, RPLS gastrectomy with D2 lymphadenectomy is feasible for the resection of gastric malignancy. RPLS offers good cosmetic outcomes and has a potential for improved postoperative recovery and pain control without compromising the oncological outcomes.